ATI RN
ATI Mental Health 2023 II Questions
Extract:
Question 1 of 5
A nurse is caring for a client who is undergoing electroconvulsive therapy. Which of the following actions should the nurse perform?
Correct Answer: B
Rationale: The correct answer is B: Check the client's condition after the procedure. After electroconvulsive therapy, the nurse should closely monitor the client for any adverse effects such as confusion, disorientation, or physical injuries. This is crucial in ensuring the client's safety and well-being post-treatment.
A: Assisting the client to ambulate may not be safe immediately after the procedure due to potential disorientation or weakness.
C: Atropine is not typically given before electroconvulsive therapy; its use would not be appropriate in this context.
D: Witnessing the client's signature on the consent form is important but is not a direct action related to the client's immediate post-procedure care.
Question 2 of 5
A nurse is beginning a therapeutic relationship with a client. The nurse should plan to accomplish which of the following tasks during the working phase?
Correct Answer: B
Rationale: The correct answer is B: Evaluate progress toward predetermined goals. During the working phase of a therapeutic relationship, the nurse and client work together to achieve established goals. Evaluating progress helps assess the effectiveness of the interventions and adjust the plan as needed. This step is crucial for fostering client growth and addressing any barriers to achieving the desired outcomes.
A: Informing the client about confidentiality rights is important but typically occurs in the orientation phase to establish trust.
C: Establishing boundaries is usually addressed in the orientation phase to clarify roles and expectations.
D: Setting short- and long-term objectives is part of the planning phase, not the working phase.
Extract:
Nurses' Notes
1100:
Client is alert and oriented x 4. The client exhibits positive self- esteem. No negativity noted during conversation. Preparing client for discharge to partial-hospitalization program.
1230:
Client requests smoked turkey club sandwich for lunch. Education regarding medications provided. Exhibit 2
Patient Data
Medications
Phenelzine
Ibuprofen
Acetaminophen
Patient Data
Question 3 of 5
When educating the client about their medication, the nurse should teach the client that there is risk for ___ due to ___
Correct Answer: A,B
Rationale: Action to Take: A, B; Potential Condition: C; Parameter to Monitor: D, E.
Rationale:
1. Action A (Hypertensive crisis) and B (Ingestion of tyramine) are correct because certain medications, like MAOIs, can interact with tyramine-rich foods leading to hypertensive crisis.
2. Potential condition C (Infection) is incorrect as it is not directly related to educating the client about medication risks.
3. Parameters to monitor D (Agranulocytosis) and E (Rhabdomyolysis) are incorrect as they are not typically associated with MAOI medication education.
Extract:
Physical Examination
Day 1 0900:
A client who has a urinary tract infection is admitted for treatment with IV antibiotics. The client is alert and oriented x3. Respirations are equal and unlabored bilaterally. S1 and S2 heart tones noted upon auscultation. Client has hearing loss and wears glasses. Abdomen is soft with suprapubic pain on palpation rated as a 4 on a scale of 0 to 10. Client reports three episodes of urinary incontinence. Bowel sounds active in all four quadrants. Able to move all extremities.
Vital Signs
Day 1 0915:
Temperature 37.3° C (99.1° F)
Heart rate 90/min
Respiratory rate 15/min
Blood pressure 130/76 mm Hg
Oxygen saturation 97% on room air
Day 1 1900:
Temperature 37.3° C (99.1° F)
Heart rate 99/min
Respiratory rate 16/min
Blood pressure 136/88 mm Hg
Oxygen saturation 98% on room air
Nurses' Notes
Day 1 1900:
The client is alert and is oriented to person, with confusion about time and place. Client is unable to focus. The client exhibits agitation upon assessment. Client states they do not remember coming to the facility, and they are late for a provider's appointment. Reorientation to environment initiates anxiety and worsens the agitation.
Question 4 of 5
Upon assessment, the nurse should recognize that the client is at risk for developing ___ as evidenced by the client’s ___
Correct Answer: A,B
Rationale: Action to Take: A, B; Potential Condition: C; Parameter to Monitor: D, E.
1. Delirium (
A) and Orientation (
B) are correct actions to take as they are common indicators of cognitive impairment and risk for adverse events.
2. Dementia (
C) is the potential condition the client is at risk for developing due to cognitive decline.
3. Monitoring Stroke (
D) is important as it can lead to cognitive impairments and increase the risk of developing dementia.
4. Monitoring Hearing Loss (E) is also crucial as it can impact communication and exacerbate cognitive decline.
Extract:
Diagnostic Results
Day 1 at 1530:
WBC count 7,700/mm3 (5,000 to 10,000/mm3)
Indicates Potential Improvement
Indicates Potential
Worsening
Hgb 14% (12% to 16%)
Hct 42% (37% to 47%)
Day 2 at 0600:
Lithium level 1.9 mEq/L (less than 1.5 mEq/L) Glucose level 90 mg/dL (74 to 106 mg/dL)
Vital Signs
Day 1 at 1600:
Temperature 37° C (98.6° F) Respiratory rate 18/min
Pulse rate 84/min
Blood pressure 114/64 mm Hg
Day 2 at 0800:
Temperature 36.9° C (98.4° F)
Respiratory rate 16/min
Pulse rate 88/min
Blood pressure 98/56 mm Hg
Medical History
Day 1 at 1500:
Bipolar disorder
Laparoscopic appendectomy at age 8 years old
Physical Examination
Day 1 at 1600:
Client reports mild nausea. Fine hand tremors noted. Lungs clear, bowel sounds active
Day 2 at 0630:
Client awake but appears fatigued. Movements and speech somewhat slowed. Lungs clear, abdomen soft with active bowel sounds. Client voided a large amount of dilute yellow urine. Uncoordinated gait noted when ambulating to bathroom. Client reports blurred vision and noted to frequently rub eyes. Client fell asleep prior to end of assessment.
.
Question 5 of 5
The nurse is reviewing the client’s medical record at 0830 on day 2 of admission. For each finding, click to specify whether the finding indicates a potential improvement in or a potential worsening of the client’s condition.
| Options | Indicates Potential | Indicates Potential |
|---|---|---|
| Blurred vision | ||
| Blood pressure | ||
| Urine amount and color | ||
| Lithium level | ||
| Gait when ambulating |
Correct Answer:
Rationale:
Correct
Answer:
Rationale:
Blurred vision can indicate a potential worsening of the client's condition, as it may suggest neurological issues or medication side effects. Blood pressure can indicate potential improvement or worsening depending on the context. Urine amount and color are crucial indicators of renal function, so changes can indicate improvement or worsening. Lithium level monitoring is essential for clients on lithium therapy to prevent toxicity or ineffectiveness. Gait when ambulating is not provided in the choices, so it does not apply to this scenario.